Registration
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Inclusive Teen Social Night for ages 11 and up and all abilities welcome!
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End Date/Time:
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Family Information & Student Background Info
First Name:
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Last Name:
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Type
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Caregiver
Father
Guardian
Mother
Parent
Self
Home Phone:
Cell #:
Work #:
Email:
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(Emails are kept confidential)
Address:
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City:
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State:
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Zip:
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Emergency Contact Info (Not Contact #1 or #2)
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Students entered below will be added to your family's account
Add New Student #1:
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Student's First Name:
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Last Name:
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Birth Date:
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(format=mm/dd/yyyy)
Is your child able to follow 1 step directions? (wait, stop, go):
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How does your child primarily communicate?:
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What situations, events, and/or types of stimuli could cause your child to have a meltdown? :
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Is your child able to organize his or her behavior after a meltdown and return to task?:
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How does your child react to other children in a social setting?:
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#1 Primary Goal for Student :
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#2 Primary Goal for Student:
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#3 Primary Goal for Student :
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Child's favorite activities?:
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Add'l info? Fears, likes, etc?:
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Add New Student #2:
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Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Is your child able to follow 1 step directions? (wait, stop, go):
*
How does your child primarily communicate?:
*
What situations, events, and/or types of stimuli could cause your child to have a meltdown? :
*
Is your child able to organize his or her behavior after a meltdown and return to task?:
*
How does your child react to other children in a social setting?:
*
#1 Primary Goal for Student :
*
#2 Primary Goal for Student:
*
#3 Primary Goal for Student :
*
Child's favorite activities?:
*
Add'l info? Fears, likes, etc?:
*
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Is your child able to follow 1 step directions? (wait, stop, go):
*
How does your child primarily communicate?:
*
What situations, events, and/or types of stimuli could cause your child to have a meltdown? :
*
Is your child able to organize his or her behavior after a meltdown and return to task?:
*
How does your child react to other children in a social setting?:
*
#1 Primary Goal for Student :
*
#2 Primary Goal for Student:
*
#3 Primary Goal for Student :
*
Child's favorite activities?:
*
Add'l info? Fears, likes, etc?:
*
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Is your child able to follow 1 step directions? (wait, stop, go):
*
How does your child primarily communicate?:
*
What situations, events, and/or types of stimuli could cause your child to have a meltdown? :
*
Is your child able to organize his or her behavior after a meltdown and return to task?:
*
How does your child react to other children in a social setting?:
*
#1 Primary Goal for Student :
*
#2 Primary Goal for Student:
*
#3 Primary Goal for Student :
*
Child's favorite activities?:
*
Add'l info? Fears, likes, etc?:
*
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Birth Date:
*
(format=mm/dd/yyyy)
Is your child able to follow 1 step directions? (wait, stop, go):
*
How does your child primarily communicate?:
*
What situations, events, and/or types of stimuli could cause your child to have a meltdown? :
*
Is your child able to organize his or her behavior after a meltdown and return to task?:
*
How does your child react to other children in a social setting?:
*
#1 Primary Goal for Student :
*
#2 Primary Goal for Student:
*
#3 Primary Goal for Student :
*
Child's favorite activities?:
*
Add'l info? Fears, likes, etc?:
*
Questions/Options:
Does your child have any known allergies? Please provide any details or write NONE
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Does the child have a diagnosis ? If so, please specify any accommodations or assistance needed
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Will you be sending dinner or would you like us to provide dinner?
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Are there are any favorite snacks (or ones to stay away from)?
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Do you consent to photos/videos being used for marketing via social media (Facebook, Instagram, and/or our company website) and/or records of activities or events in published materials?
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Yes
No
Additional Information:
Drop off and Pick Up
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Drop off is anytime at 5:30 and later and all kids must be picked up by 9:00pm. Any child picked up more than 10 minutes late will incur a $15 charge for every 10 minutes after.
I've read the above and agree.
What to Bring
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Please bring a water bottle and any snacks or dinner if they prefer to bring their own. We will provide snacks, sparkling water and pizza.
I've read the above and agree.
Enroll/Cancel Policy
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Registration is not confirmed until payment is received. You may receive a 50% refund if cancelled within 48 hours. Any cancels within the 48 hour time frame will not be subject to refunds.
I've read the above and agree.
Behavior Policy
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We understand all kids exhibit different behaviors in different environments and that is most often a form of communication. In our group setting for a Teen Social Night, we want to ensure all children and staff remain safe. If we observe a child exhibiting behaviors towards others or self or staff such as but not limited to: hitting, biting, throwing, kicking, pinching, shoving, or any sort of destruction of property, parents will be notified immediately and asked to pick up your child. In this particular setting we do not have the ability to provide consistent direct 1:1 support to maintain safe behaviors.
I've read the above and agree.
Release of Liability
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I understand that gymnastics is a sport involving height and motion, which creates risk and the possibility of accidental injury. I have been advised and fully understand that certain elements of danger are inherent in the activities (gymnastics, yoga, strength training, camps, etc.) sponsored by Flip for Function, PLLC which are beyond the control of the instructors, agents, officers, students, and employees of Flip for Function, PLLC, and that participation in any program activities may entail unavoidable risk of personal injury and death. I hereby assume all risks of injury and death to myself (or my child) arising out of my or my child's participation in such activity and I agree to indemnify, hold harmless Flip for Function, PLLC, its officers, instructors, agents, and employees (“Releases”) from and against all claims arising from any occurrence causing damage or injury to myself, my child or to any party participating in said event or any third parties injured as a result of my actions. I further agree to repair or reimburse Flip for Function, PLLC for any and all damages that I or my child cause to Flip for Function, PLLC property or the property at which a specific activity is held. I agree to indemnify and hold harmless Flip for Function, PLLC against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney's fees and any related costs, if litigation arises pursuant to any claims made by me or by anyone else acting on my behalf. If Flip for Function, PLLC incurs any of these types of expenses, I agree to reimburse Flip for Function, PLLC.
Prior to signing below, I have read and understand the terms and conditions of this Release, Indemnification, and Waiver, understand by signing below I am waiving certain legal rights I may have against the Releasees, and I agree to subscribe to all the terms and conditions set out above.
I've read the above and agree.
Media Release
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Flip for Function recognizes the need to ensure the welfare and safety of all individuals taking part in any activity associated with our company.
In accordance with our child protection policy we will not permit photographs, video or other images of young people to be taken without the consent of the parents/guardians. As your child will be taking part in therapy at our facility, we would like to ask for your consent to take photographs/videos that may contain images of your child.
It is likely that these images may be used as
• a record of therapeutic progress
• a description of therapeutic procedures, exercises, or activities
• marketing via social media (Facebook, Instagram, and/or our company website)
• records of activities or events in published materials
Flip for Function will take all steps to ensure these images are used solely for the purposes they are intended. If you become aware that these images are being used inappropriately, please inform our staff immediately.
By checking "I agree" you are acknowledging that you have read this release but not giving consent for the use of images unless provided previously.
I've read the above and agree.
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